Scott Webb (Host): When it comes to all forms of cancer, including breast cancer, early diagnosis is essential. And my guest today is here to tell us about the role that screening mammograms, MRIs, and ultrasounds play in diagnosing breast cancer early. I'm joined today by Dr. Divya Kishore. She's a radiologist with Salinas Valley Health.

 This is Ask the Experts, the podcast from Salinas Valley Health. I'm Scott Webb. Doctor, it's so nice to have you here today. We're going to talk all things breast cancer screening, if you will, mammograms and MRIs and ultrasounds and a whole bunch of good stuff for listeners. But before we get there, just be kind of broadly, like why is breast cancer screening so important in your world, in your mind, in your expertise, and at what age should women start getting mammograms?

Dr. Divya Kishore: Breast cancer screening is important because the earlier we catch cancer, the easier it is to treat. Often when a cancer is caught on a screening mammogram or sometimes a screening MRI, depending on who you are, you don't even feel anything in your breast. So, the earlier that we find a tumor, the easier it is to treat it.

Host: And are there some guidelines in terms of screening, when to start screening? I know they've changed some of the—thinking about colonoscopies, for example. Is that true of mammograms as well? Are women generally encouraged to get them earlier, sooner? Is family history a part of it? Take us through that.

Dr. Divya Kishore: Yeah, absolutely. So, for your average patient, annual screening mammograms should start at age 40, and that's every year. So, that's our recommendation that you start at age 40 getting your regular screening mammogram. That means that you're not waiting until you feel a lump, or you see something, or you're worried about something. It's just part of your annual sort of preventative healthcare workup.

Now, some people have to start earlier, and that's depending on their own circumstances, such as family history or personal history. If you have a family history of breast cancer, if you have first-degree relatives, that means like a mother, a sister, then you need to start sooner. So, that can start as early as age 30.

And then, there's also something called a risk assessment. That is something that your doctor can do. It can also be something that we do at our breast imaging clinic. We ask you a few questions. And that'll tell us what your risk of developing breast cancer your whole life is.

So, if let's say the risk score assessment comes out to 5%, that means that there's a 5% chance that you'll develop breast cancer at some point throughout your life. We've determined that if that number is 20% or higher, then you need extra special screening, and that comes in the form of starting your mammogram sooner, and also getting MRIs in addition to your mammograms.

Host: Yeah. And in terms of the breast cancer risk assessment, is there a starting age for that? Can folks do that with their primary care physicians? Take us through that process a little bit.

Dr. Divya Kishore: The recommendation from the Society of Breast Imaging is that everybody get a risk assessment by the time they're 25 years old. That allows us to capture the patient population who needs to start screening early, such as at age 30. That's something that you can do with your primary care doctor or your OB- GYN.

There are also risk score assessment tools online. I always recommend doing it with your doctor just so that you have somebody walking you through the results, and also capturing the results in a meaningful way, but you can also go online and calculate the score yourself.

Host: So then, Doctor, if an individual, a patient is considered high-risk, you said 20%, right? If I heard that right, so 20%, then what happens next? Is it just, like, head right for the mammogram after that, or is there still some time?

Dr. Divya Kishore: So, from age 30 onwards in a patient who's high risk, they would alternate every six months with a screening mammogram and a screening MRI. That means that, let's say, your birthday is in January, you might get your mammogram in January of that year. And then, in June or July, you would get your MRI, and you would alternate and do that every single year.

Now, if you are in some special circumstances, based on your family history, or if you had a childhood cancer that required chest radiation, you might start doing screening at age 25. In those cases, you just start with an MRI every year until you're 30, and then you start with mammogram.

Host: Switch to mammograms, right. Yeah. And in terms of mammograms, Doctor, when something doesn't look right, whatever that means exactly to an expert like yourself, when something's not right, what happens next? Like what's the next steps, or additional screenings and so forth?

Dr. Divya Kishore: Yeah. So, what happens when you come for a mammogram, you come, you take certain images. Usually, it's about four pictures, two on each breast. You go home. And at a different time, the radiologist reads the images. What's important here is that we also have all of your prior imaging, so we can make comparisons to the images that you've had before, if you've had them. And we can see if there have been any changes or anything suspicious that's on the imaging that we think we need to investigate further.

Now, it's important to note that most of the time, when you come back for additional evaluation, which is what we do when we see something that concerns us. It often turns out to be not cancer. But the purpose of doing your screening mammogram is to make sure that if there is anything, we're catching it early.

So, let's say I find something in your right breast, you would come back and you'd get special mammogram images that focus on that area of your breast. Depending on what we see there, we might take you to ultrasound, which is a different type of imaging, so that we can get a better look at that area.

Host: Yeah. Let's drill down a little bit, if you will, and talk a little bit more about MRIs and ultrasounds and how they sort of maybe complement mammograms, you know, when you go from mammogram to those technologies, just so we have a understanding of, like, the role that all of these things play.

Dr. Divya Kishore: So, ultrasound, for the most part, is used to help us understand what we're seeing on a mammogram. It's a different type of imaging that uses sound waves instead of x-rays, so that we can characterize things in our breast, which could be anything from normal tissue, cysts, which are just little sacs of fluid and don't hurt us, to the other end of the spectrum, which is cancer.

No single modality—so, mammogram, ultrasound, or MRI—is perfect on their own, which is why we use all of them in conjunction with one another. An MRI is a completely different type of test that takes place in a different room, where you're lying down on your belly and you're going into a little tube, and we're getting some images in a different way.

Host: Yeah. And you gave us a sense there of how they all sort of work together and complement each other and depending on the, you know, patient and personal history, family history, all of that, all those things play a factor. But you have emphasized today, Doctor, that early diagnosis is key, and that's why we're talking about, you know, risk assessment and screenings.

As you said earlier, there aren't often a lot of symptoms, especially, you know, for patients early on, maybe give women a sense—even men—a sense of what shouldn't be ignored if there's anything, like, even between screenings, like, what shouldn't we ignore?

Dr. Divya Kishore: So, a few things. If you start feeling a new lump, that's important to come and to get it checked out. We often have lumpy, bumpy tissue. Oftentimes, a lump ends up being normal breast tissue that's responding to hormones, but it also can be how cancer presents. So, if you feel a new lump, come and get it checked out with a mammogram and an ultrasound.

If you notice any skin changes, so your skin starts looking thicker if it starts dimpling, meaning you start seeing little indentations or dimples, if the skin starts looking different, almost like the skin of an orange peel, those are types of changes that you don't want to ignore, even if you don't feel a lump. You'd want to come in and get that area checked out as well.

If you start experiencing discharge from your nipple, especially if it's bloody, or if it's clear, but any type of discharge from your nipple, you want to race to your doctor, and we'll go ahead and check that out because sometimes cancer can present as, you know, sending fluid through your nipple. And then, with your nipple, if you notice that it's changing in its shape, so if it's we call it geting inverted, meaning it starts pointing inwards instead of outwards, that's also a concerning sign that we would want to get checked out as well.

Host: Yeah. I'm sure, Doctor, that folks have some anxiety, and maybe try to avoid screenings in some cases. What would you say to them to reassure them that, in most cases, cancer is not found, that it's relatively painless, you know, that kind of thing.

Dr. Divya Kishore: Totally understandable to be nervous, but know that screening is the most empowering step that you can take because it gives you the best odds of finding something early instead of later. And when you find something earlier, you're much more likely to have a better outcome.

Host: Right. Yeah. And that's the end game here, is not to scare people, but to encourage them. If they have a personal history of cancer or a family history of breast cancer, you know, get that risk assessment, be screened, you know, followup, all that. And, Doctor, we find sometimes that the last thing an expert says in a podcast is the one thing that folks remember, the key takeaway. So here at the end, if there was just one thing you want listeners to take away from this, a key takeaway in terms of breast cancer screening, what would it be?

Dr. Divya Kishore: Yeah. So, when we do annual screening, we start finding cancers really early, I mean, when they're less than half a centimeter big, and that makes a really big difference in treating cancer compared to when you see it after it's grown and you start feeling it. So, I encourage people to try to come in annually, get their screening mammogram, talk to their doctor about whether they need any extra types of screening, and just know that prevention is everything. So, finding things early is everything.

Host: That's perfect. Well, I appreciate your time and your expertise today. Thanks so much

Dr. Divya Kishore: Of course. Thanks so much.

Host: And to listen to more of our podcasts, please visit salinasvalleyhealth.com/podcasts. And if you found this podcast to be helpful, please be sure to tell a friend, neighbor, or family member. And subscribe, rate and review this podcast, and check out the entire podcast library for additional topics of interest. This is Ask the Experts from Salinas Valley Health. I'm Scott Webb. Stay well, and we'll talk again next time.